Relapsing cardial stenosis after laparoscopic nissen treated by esophageal stenting.

Dysphagia after antireflux surgery is often a challenging situation. We report the case of a patient with relapsing cardial stricture and a weight loss of 24 kg following a laparoscopic Nissen procedure. Initial presentation was consistent with the diagnosis of pseudoachalasia and was resistant to endoscopic dilatation. Dysphagia was relieved by surgery, which showed cardial strangulation by tightly sutured diaphragmatic pillars. Symptoms and cardial stricture relapsed after a few months with no significant relief after repeated dilatations. Conservative treatment by endoscopic transcardial prosthesis for six weeks allowed a return to normal diet and a weight gain of 10 kg within a 30-month followup period.

[Effect of assisted ventilation and position on gastro-esophageal acid reflux after laparotomy]. / Effet de la ventilation assistée et de la position sur le reflux gastro-oesophagien acide après laparotomie.

AIMS: Gastro-esophageal reflux disease (GERD) is frequent in mechanically ventilated patients, often source of hemorragic or respiratory complications. The aim of this study was to determine promoting factors for acid reflux and to define the role of methods of ventilation and body position on reflux. METHODS: Fifteen patients with no history of GERD were included, following scheduled abdominal surgery. Reflux was measured in the proximal and distal esophagus by pH-metry. Events associated with reflux were detected by a videocamera linked to a videocassette recorder synchronized to the pH data logger. Position of the patients was randomized between supine and recumbent 30 degrees. Patients were first placed on mechanical ventilation then breathed spontaneously, determining 2 periods of equal duration during which provocative maneuvers were carried out. RESULTS: Acid reflux was absent in recumbent 30 degrees posture. Acid contact time and number of reflux in supine posture were 0.5 +/- 0.4% and 0.3 +/- 0.2/h respectively with mechanical ventilation and 4 +/- 2.5% and 1 +/- 0.5/h respectively with spontaneous breathing (P<0.05 vs position 30 degrees ) in distal esophagus. Twenty-five% of reflux episodes were associated with an event, mainly cough. CONCLUSION: Acid reflux is rare immediately following laparotomy. Seventy-five per cent of reflux occurred without any detectable event. Reflux was absent in semi recumbency. Mechanical ventilation did not facilitate reflux.

Patterns of esophageal inhibition during swallowing, pharyngeal stimulation, and transient LES relaxation. Lower esophageal sphincter.

Lower esophageal sphincter (LES) relaxation and esophageal body inhibition co-occur during esophageal peristalsis but not necessarily during pharyngeal stimulation or transient LES relaxation (tLESR). This study examined these relationships and the impact on reflux. Nine young volunteers were studied. An artificial high-pressure zone (HPZ) was established, and pH was recorded 8 and 5 cm proximal to the LES. Pharyngeal stimulation was by water injection and gastric distension with liquid or gas. Peristalsis, pharyngeal stimulation, and spontaneous events were recorded. Swallowing relaxed the LES in 100% of trials (the HPZ in 80%) and caused no reflux. Pharyngeal stimulation relaxed the LES in two-thirds of trials, had no effect on the HPZ, and caused no reflux. Gastric distension was associated with 117 tLESRs, 48% with acid reflux, and 32% with gas reflux; there was no effect on the HPZ. We conclude that LES relaxation is a necessary but not sufficient condition for reflux. LES relaxation and esophageal body inhibition are independent events that may be concurrent (swallowing) or dissociated (tLESR).